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Many people think a relationship exists between gastroesophageal reflux disease (GERD) and peptic ulcer disease. But it is important to separate GERD and ulcers, says Christian Mathy, MD, assistant clinical professor of medicine, division of gastroenterology, University of California, San Francisco: “They have separate [causes], symptoms, and treatments.”

Managing an Ulcer and GERD: Two Distinct Conditions

GERD is a disorder of the lower esophageal sphincter muscle. This muscle keeps the stomach’s acid contents in place. If it is weak, or too relaxed, then it will not function properly, and the acid will travel up into the esophagus. For most people, an ulcer, on the other hand, is a condition caused by either the bacterium Helicobacter pylori (H. pylori) or the use of non-steroidal anti-inflammatory drugs (NSAIDs).

The symptoms of the two disorders are different, too. GERD’s symptoms include a burning feeling in the sternum (breast bone) and a croaky and perhaps sore throat with an inability to swallow properly. These symptoms increase when eating.

With an ulcer, the pain occurs between the bottom of the breastbone and the navel. You might experience nausea and bloody vomit and perhaps stools, and eating actually eases the pain.

Managing an Ulcer and GERD: Which One to Treat

For people who have symptoms of both disorders, Dr. Mathy says it is important to do an endoscopic examination of the esophagus and stomach. This way, Mathy says, “you can get a sense of what is the bigger problem.” An endoscope — a long tube with a camera on one end inserted into the mouth and down the throat under sedation — can let a doctor see what is happening inside you.

The endoscopy exam can be a guide as to which condition to treat and how. “If there’s a five-centimeter ulcer in the stomach and minimal amount of GERD change, then you want to treat the ulcer. On the flip side, if there’s minimal stomach involvement and horrible esophageal erosion, you should concentrate on the GERD,” Mathy says.

To treat GERD, the patient will need long-term acid-suppressant care, usually with a medication called a proton pump inhibitor. Mathy says it’s a rare patient who will be tapered off therapy.

For a larger ulcer, the usual course is to look for an H. pylori infection, then treat it with two weeks of antibiotics, followed by two months of a proton pump inhibitor to lower acid levels in the stomach and promote healing.

Managing an Ulcer and GERD: Problems with Dual Diagnosis

There are two main types of H. pylori infection. One causes problems lower in the stomach and generally increases the acid content, while the other, according to Mathy, leads to low acid levels throughout the stomach.

“This doesn’t play a role in the [cause] of GERD, and it may actually be protective,” Mathy explains. If your stomach’s not making acid, then you’re less likely to get GERD.” This is because even though the sphincter muscle may be weak and not opening properly, there is little harmful acid coming up into the esophagus.

The problem with treating H. pylori in these cases, says Wilfred M. Weinstein, MD, professor of medicine in the division of digestive diseases at the David Geffen School of Medicine at UCLA, is that “when some people get an ulcer treated, then afterwards they may get GERD for the first time.” This is because the normal acid balance is restored when the H. pylori is wiped out, so the weak sphincter muscle will now be exposed as it lets acid up into the esophagus.

Managing an Ulcer and GERD: The Balancing Act

It comes down to this, Mathy says: If the patient has symptoms of both GERD and ulcer, but the GERD symptoms are bothering the patient more, that’s what you treat. But if the patient has a huge ulcer, it must be treated, despite the odds that GERD symptoms may worsen. “We’re not going to get a handle on the gastric ulcer until we take care of the H. pylori,” Mathy explains. “It is a balancing act.”

Working with your own gastroenterologist, you will ultimately be able to develop a plan for relief and decide on the best treatment for your unique situation.

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